Published online May 1, 2006
PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1854-1856 (doi:10.1542/10.1542/peds.2006-0353)
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LETTER TO THE EDITOR

Intensivist-Led Team Approach to Critical Care of Children With Heart Disease

Harris P. Baden, MD
Jerry J. Zimmerman, MD, PhD
Department of Pediatrics
Children's Hospital and Regional Medical Center
Seattle, WA 98105

Richard J. Brilli, MD
Hector Wong, MD
Department of Pediatrics
Cincinnati Children's Hospital Medical Center
Cincinnati, OH 45229-3039

Randall C. Wetzel, MD
Department of Anesthesiology and Pediatrics
Childrens Hospital Los Angeles
Los Angeles, CA 90027

Jeffrey P. Burns, MD
Department of Pediatrics
Children's Hospital Boston
Boston, MA 02115

Vinay Nadkarni, MD
Department of Pediatrics
Children's Hospital of Philadelphia
Philadelphia, PA 19104

Paul A. Checchia, MD
Department of Pediatrics
St Louis Children's Hospital
St Louis, MO 63110

Heidi J. Dalton, MD
John Berger, MD
Murray Pollack, MD
Department of Pediatrics
Children's National Medical Center
Washington, DC 20010

Daniel Notterman, MD
Department of Pediatrics
Robert Wood Johnson Children's Hospital
New Brunswick, NJ, 08903

Thomas P. Green
Department of Pediatrics
Children's Memorial Hospital
Chicago, IL 60614-3394

Jeffrey Blumer, MD
Department of Pediatrics
Rainbow Babies and Children's Hospital
Cleveland, OH 44106

Michael Dean, MD
Department of Pediatrics
Primary Children's Hospital
Salt Lake City, UT 84113

To the Editor.

We read with great interest the article "ACC/AHA/AAP Recommendations for Training in Pediatric Cardiology."1 We would like to comment specifically on the section that described advanced training in pediatric cardiac critical care.

The practice of high-quality postoperative pediatric cardiac intensive care requires a multidisciplinary collaboration between physicians (surgeon, cardiologist, intensivist) and other clinical disciplines including nursing, respiratory therapy, pharmacology, and nutrition support. Our comments are predicated on the well-established precept that all critically ill patients are best cared for by a multidisciplinary team of clinicians with the intensivist as the team leader or co-leader.2–5 On the basis of data demonstrating better outcomes and decreased costs, groups such as Leapfrog and the National Quality Forum have mandated intensivist management of ICU patients, including pediatric patients. Published guidelines by the American College of Critical Care Medicine for PICUs offer similar recommendations.6 In addition, each specialty board in medicine, surgery, anesthesia, and pediatrics has established pathways for board certification in critical care medicine. Therefore, we submit that critically ill children in a cardiac ICU should receive care from a board-certified/eligible intensivist using the aforementioned multidisciplinary model of clinical care.

The abbreviated critical care rotations outlined in the American College of Cardiology Foundation/American Heart Association/American Academy of Pediatrics document will give the cardiologist added critical care experience, but this additional clinical exposure does not transform a cardiologist into an intensivist any more than a few clinical months of cardiology training could convert an intensivist into a cardiologist. The training for any physician who wishes to practice pediatric critical care medicine or any other pediatric subspecialty should not be fast-tracked. The specific areas of proposed knowledge and competence outlined in the guidelines are similar to the full curriculum of an entire critical care medicine fellowship, including (but not limited to) the management of increased intracranial pressure, coagulation disorders, advanced ventilator management techniques, renal failure management, and nutrition support. It takes a full 3 years of a critical care medicine fellowship to begin to master these concepts; therefore, we feel that 9 months of additional clinical training beyond a standard cardiology fellowship is insufficient to produce clinicians capable of fulfilling the "intensivist" role in the cardiac ICU.

In sum, all critically ill children, including those in a cardiac ICU, should be cared for by a team of clinicians including (but not limited to) board-certified critical care medicine specialists. The physician who wishes to fulfill both the cardiologist and intensivist roles in the cardiac ICU should follow the 5-year path outlined by the American Board of Pediatrics for dual certification in both cardiology and critical care medicine. There can be no shortcuts in the care of critically ill children. We advocate a model of care that incorporates all relevant clinical experts and that such a model is most consistent with the highest-quality critical care practice.

Last, it is our view that the process whereby the American Academy of Pediatrics participated in the co-sponsorship of the training guidelines was flawed. We believe that proposals for advanced training by one pediatric subspecialty that impact the care provided by another pediatric subspecialty require careful and collaborative forethought. Furthermore, given the clear stance by the American Board of Pediatrics regarding dual certification for pediatric subspecialists who wish to practice in multiple areas of pediatrics, we believe the final conclusions for training were in error.

REFERENCES

  1. American College of Cardiology Foundation/American Heart Association/American College of Physicians, Task Force on Clinical Competence. ACC/AHA/AAP recommendations for training in pediatric cardiology. Pediatrics. 2005;116 :1574 –1596[Free Full Text]
  2. Brilli R, Spevetz A, Branson R, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med. 2001;29 :2007 –2019[Abstract/Free Full Text]
  3. Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M. Impact of quality of care factors on pediatric intensive care unit mortality. JAMA. 1994;272 :941 –946[Abstract/Free Full Text]
  4. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA. 2002;288 :2151 –2162[Abstract/Free Full Text]
  5. Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med. 2001;29 :753 –758[CrossRef][Web of Science][Medline]
  6. Rosenberg DI, Moss MM; American College of Critical Care Medicine of the Society of Critical Care Medicine. Guidelines and levels of care for pediatric intensive care units. Crit Care Med. 2004;32 :2117 –2127[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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L. Su and R. Munoz
Isn't It the Right Time to Address the Impact of Pediatric Cardiac Intensive Care Units on Medical Education?
Pediatrics, October 1, 2007; 120(4): e1117 - e1119.
[Full Text] [PDF]

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